Form L-2057 - Application For Bingo Promoter'S License (Page 4 of 4) in pdf

L-2057 INSTRUCTIONS - FOR THE COMPLETION OF

APPLICATION FOR BINGO PROMOTER'S LICENSE

(Rev. 9/24/08)

All blanks on the application must be filled in either by a definite answer or "not applicable". The thirty (45) days allowed

by statute for processing the application does not begin until the application is properly completed and all required

supporting documents are received.

Indicate type of ownership in proper square.

1. Record the name of the applicant. The name of the corporation must be given exactly as chartered. We cannot

accept any deviations. If the applicant is an individual, provide Social Security number; if the applicant is a

partnership provide Social Security number and/or Federal Employer Identification number; if the applicant is a

corporation, provide Federal Employer Identification number.

Provide permanent street address of applicant, mailing address, and telephone number. If applicant is an individual,

give drivers license number with the state which issued the license and date of birth. If applicant is a corporation or

partnership, indicate in "Date of Birth" the date incorporated or organized.

The name must be exactly as chartered, no deviations accepted. Provide address and file number of the

organization.

3. Indicate if you are leasing or renting equipment, furniture, fixture or building to an organization. You must attach a

copy of the lease or rental agreement; you also must have a sales tax license and remit the sales tax number on the

lease payments.

Indicate if you are leasing/renting the building used for bingo from any individual or organization.

Indicate if you are a party to any contract involving use of a building other than the operation of bingo.

Indicate the number, if any, of the promoter's license you currently hold.

Give the number, if any, of the promoters license pending.

Indicate if you have a bond on file with the Department of Revenue and give the value of that bond. If not, please

submit a bond with the application. The bond must be in the exact name of the applicant. See number one.

Give the names, address, and phone of the person or company that conducts your bookkeeping activities.

10.

Indicate if retail sales of tangible personal property will be made at the location in which the games are to be played.

If yes, please provide us with the retail license number. If you do not have a retail license you may obtain one by

completing Form SCTC-111.

11.

Indicate if there are other business activities being conducted at the bingo location. State the nature of that activity

and attach a copy of any contracts or agreements.

12.

Give information on all partners, officers and stockholders of ten percent or more. Information must include Name,

Position Held, Home Address, Social Security Number, Phone Number, and Date of Birth.

Give information on all employed persons who will receive compensation for work performed. Information must

13.

include Name, Home Address, Work to be Performed, Home Address, Social Security Number, Phone Number, and

THE AFFIDAVIT MUST BE COMPLETED IN FULL

41364027

Form L-2057 - Application For Bingo Promoter'S License Page 4